Pollack: I assume you are relieved by the election. But I take it that you are pretty concerned moving forward. What do you see as the two or three biggest challenges between now and 2014, when the exchanges officially are slated to kick in?

Starr: The biggest challenges before 2014? In the fall of 2013, open enrollment is supposed to begin for the insurance exchanges. Yet according to Ron Pollack of Families USA, a recent poll by Celinda Lake showed that 78 percent of the uninsured are unaware of the new opportunities for coverage under the law.

Moreover, the legislation did not provide any funds for public education, and the 30 or so state governments controlled by Republicans aren’t going to spend money to educate the public about the exchanges. So there is a significant possibility that the number of people insured through the exchanges will fall substantially short of projections.

In addition, it’s not clear yet whether the federal government will have the capacity to launch a federal exchange successfully. It would be one thing if a federal exchange had been planned from the beginning; it’s a different matter when states decide to leave it to the federal government with less than a year before open enrollment, and without a specific appropriation for a federal exchange. How this is going to work is at least unclear.

And then there’s the likelihood that many states will not carry out the Medicaid expansion, at least not to start with.

The whole thing is quite interesting (and not too long) but I think this observation is key:

Starr: Health care is so large a part of the federal government that presidents cannot avoid the issue. But if the ACA fails, will another Democratic president attempt to achieve universal coverage a different way? I’m not sure.

It depends how bad things get. If the Republicans had won the election, repealed the ACA, and block-granted Medicaid under the formula that Paul Ryan favored, we’d be looking at 60-70 million uninsured. That still might happen after 2016, and it might prompt yet another effort. This battle is going to be with us a long time.

We're still fighting them on the New Deal programs and they were conceived nearly 80 years ago. I can't imagine that the right is going to stop attacking health care reform and the complacency of many on the left about this continues to astonish me. The idea that the Republicans will not only give up on repeal but allow the Democrats to add to the program as needed (which many ACA advocates promised would happen) has always struck me as a utopian view of current American politics. What happened in the past is not a good guideline for an era of extreme polarization and an ideologically rigid opposition. These things were very hard to do even in a time of liberal consensus.